Monday, 20 May 2013

A systematic review in The Lancet has concluded: 'Women's groups practising participatory learning and action led to substantial reductions in neonatal and maternal mortalities in rural, low-resource settings'.

'The results of our study raise three important issues. First, is the potential of community-based, participatory interventions to reduce maternal mortality [...] For women's groups, we hypothesise that reduction of maternal mortality might be driven by reduced infection through improved uptake of antenatal care and hygiene during delivery, and small changes in the rapidity of response and care-seeking that make the difference for survival. [...] Second, the results of the analysis raise the question of whether participatory learning and action have a role in maternal and newborn health in urban contexts. [...] Last, we should consider how community strategies that were shown to be effective in small-to-medium-sized trials, including home visits and collective action through women's groups, could be combined at scale. [...] In [rural] settings, policy makers should consider women's groups as a core strategy to complement efforts made to improve safer motherhood and newborn care through better midwifery and obstetric care.'

Below is the citation and summary. The full text of both is freely available after free registration.

An accompanying editorial by Cesar Victora and Fernando Barros calls for scaling up of the approach 'vigorously in a selected number of countries, accompanied by rigorous evaluations'.[...] 'This approach would provide rigorous evidence about how participatory interventions, when scaled up, will deliver what they promise. Let us not allow yet another innovative, potentially life-saving intervention to be scaled up without proper evaluation.' http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61029-6/fulltext

SUMMARYBackground: Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings.

Methods: We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries.

Findings: Seven trials (119 428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 37% reduction in maternal mortality (odds ratio 0·63, 95% CI 0·32-0·94), a 23% reduction in neonatal mortality (0·77, 0·65-0·90), and a 9% non-significant reduction in stillbirths (0·91, 0·79-1·03), with high heterogeneity for maternal (I2=58·8%, p=0·024) and neonatal results (I2=64·7%, p=0·009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0·026 and p=0·011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0·45, 0·17-0·73) and a 33% reduction in neonatal mortality (0·67, 0·59-0·74). The intervention was cost effective by WHO standards and could save an estimated 283 000 newborn infants and 41 100 mothers per year if implemented in rural areas of 74 Countdown countries.

Interpretation: With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings.

Funding: Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

HIFA2015 profile: Neil Pakenham-Walsh is the coordinator of the HIFA2015 campaign and co-director of the Global Healthcare Information Network. He is also currently chair of the Dgroups Foundation (www.dgroups.info), a partnership of 18 international development organisations promoting dialogue for international health and development. He started his career as a hospital doctor in the UK, and has clinical experience as an isolated health worker in rural Ecuador and Peru. For the last 20 years he has been committed to the global challenge of improving the availability and use of relevant, reliable healthcare information for health workers and citizens in low- and middle-income countries. He is particularly interested in the potential of inclusive, interdisciplinary communication platforms to help address global health and international development challenges. He has worked with the World Health Organization, the Wellcome Trust, Medicine Digest and INASP (International Network for the Availability of Scientific Publications). He is based near Oxford, UK. www.hifa2015.org ; neil.pakenham-walsh AT ghi-net.org__________

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After service in the British SAS Regiment the author became a physician and then an orthopaedic surgeon.
He has held professorial positions in Canada, Vietnam and the United States, practiced and taught orthopaedic surgery in three continents and in several wars.
He has extensive experience as an expert witness in court. Somewhere along the way, time was found to operate a four hundred acre mixed farm, a one hundred seat restaurant and to obtain a licence as a flying instructor.
The author's books are available from bookstores, the publishers, or from on-line bookstores such as Amazon, Barnes and Noble, and Indigo/Chapters.
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